July 2011

French study favors Ponseti over compatriots’ technique

Casting simplifies clubfoot management

By Emily Delzell

Ponseti serial casting for clubfoot continues to gain traction in the U. S. and abroad—even in France, the birthplace of an alternate nonsurgical therapy.

In a comparative study published in the April/May issue of the Journal of Pediatric Orthopaedics, French researchers found that Ponseti casting compared favorably to French physiotherapy for initial treatment of idiopathic clubfoot.1

French physiotherapy, or the functional method, originated in the 1970s in France and has been used in the U.S. since the mid-1990s. The technique involves gradual, progressive stretching of medial soft tissue and bony structures; passive reduction of the talonavicular joint; sequential correction of forefoot adduction, hindfoot varus, and calcaneal equines; muscle strengthening and stimulation; and, when appropriate, heel-cord tenotomy. It also requires active participation of the patient’s parents, who must take part in the daily home program of exercise, elastic taping, and splinting.2

Ponseti casting focuses on global correction of the clubfoot over six to eight weeks, and heel-cord release is performed in most patients.2

“In 1995, French physician Alain Dimeglo came to our hospital to teach the physiotherapy method. We continue to use it, along with Ponseti casting, which we began using around the same time,” said Stephen Richards, MD, an orthopedic surgeon and assistant chief of staff and medical director of inpatient services at the Texas Scottish Rite Hospital for Children in Dallas. “We found that adding heel-cord release to French physiotherapy allows us to achieve initial correction in 95% of clubfeet, a very similar rate to that of the Ponseti method.” 2

Meanwhile, in France, French physiotherapy had been the main method of clubfoot management until Ignacio Ponseti introduced his method to that country in 1999, said Franck Chotel, MD, PhD, an orthopedic surgeon at the Hôpital Universitaire Mère Enfant de Lyon in Bron, France.

“This [French] method is more critically dependent on the therapist’s skills than the Ponseti method, which can lead to inconsistent results,” Chotel said. “The excellent results with the Ponseti method were viewed initially with surprise and suspicion, and it took about 10 years and much discourse before it gained acceptance. Today about 80% of French pediatric orthopedists apply a pure or variant form of the Ponseti method, though there is still considerable resistance in Paris, where the functional method was born.”

Chotel also noted that proximity to a skilled therapist plays a role in functional method outcomes—parents typically bring the child in for initial treatment five times a week—and that not all health care systems cover the frequent care needed for success.

In the JPO study, Chotel and colleagues looked at 219 clubfeet in 149 children, placing patients into two groups. Clinicians treated 116 clubfeet with French physiotherapy (FM group) and 103 clubfeet with Ponseti casting (PM group).

The need for surgery beyond heel-cord tenotomy was considered failure of nonoperative management, and investiga­tors ranked complete posteromedial release as a poor result and limited posterior release as fair, while nonrelease surgery or nonoperated feet were scored based on a modified Ghanem scale emphasizing morphology and function.

After a mean follow-up of 5.5 years, surgery had been performed at a similar rate in both groups (21% in the FM group, 16% in the PM group) but complete posteromedial release was mainly done in the French physiotherapy group (19% of feet), while only nonrelease surgery was done in the Ponseti group.

Excellent, good, fair, and poor results occurred in, respectively, 55%, 20%, 6%, and 19% of patients in the FM group and 79%, 15%, 4%, and 2% of patients in the PM group. Results for Dimeglio grade II clubfeet were equivalent between groups, but results for grade III and grade IV clubfeet were better in the PM group.

“We believe the Ponseti method is the treatment of choice for management of clubfeet,” said Chotel. “It is reproducible and reduces the need for extensive surgery.”

In addition, Chotel noted, research3 has found French physiotherapy is four times more expensive during the first year of management than the Ponseti method.

“The Ponseti method produces excellent results and is less expensive and labor-intensive than French physiotherapy; that’s why it has emerged as the conservative treatment of choice in the U.S. and elsewhere,” said Richards, who noted that prior to using the Ponseti or French methods at TSRHC about 85% of infants’ feet required full posteromedial release. “Now, although relapses occur in 10% to 15% of children, excellent results can be achieved with both methods when the proper level of expertise is available.”

One Response to French study favors Ponseti over compatriots’ technique

Corrective clubfoot cast treatment was also developed and/or originated by Micheal Hoke of Atlanta, Georgia and later continued by John Royal Moore at the Philadelphia Shriner’s Hospital. Their use of a non-operative serial casting treatment method was developed in the 1920’s – long before Ponseti’s similar method.
I used the Hoke – Moore method effectively during my career at the Lovelace Medical Center in Albuquerque.
As a 1954 graduate of the State University of Iowa College of Medicine, I have great respect for Dr. Ponseti and his career. My orthopedic residency was completed in San Francisco and Philadelphia.